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General NPI Number Information
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NPI Number | 1063571222
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Entity Type | Organization
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Legal Business Name | GOLDEN AGE HOME
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Dates
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Enumeration Date | 12/06/2006
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Last Update Date | 08/22/2020
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Provider Practice Location Address
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Address Line | 1505 S MAIN ST
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City | LOCKHART
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State | TX
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Zip | 78644-3945
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Country | US
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Telephone | 512-398-2362
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Fax | 512-398-5591
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Provider Business Mailing Address
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Address Line | 1505 S MAIN ST
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City | LOCKHART
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State | TX
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Zip | 78644-3945
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Country | US
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Telephone | 512-398-2362
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Fax | 512-398-5591
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Authorized Official
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Title or Position | EXECUTIVE DIRECTOR
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Name | MS. MARY E. CARROLL
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Credential | NFA
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Telephone | 512-398-2362
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 314000000X
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Taxonomy Name | Skilled Nursing Facility
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License Number | 116823
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License Number State | TX
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